Provider Demographics
NPI:1720695190
Name:GOSS, KIMBERLY FAYE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:FAYE
Last Name:GOSS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 PLEASANT RDG
Mailing Address - Street 2:
Mailing Address - City:MOOREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38857-5001
Mailing Address - Country:US
Mailing Address - Phone:662-231-0741
Mailing Address - Fax:
Practice Address - Street 1:830 S GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4996
Practice Address - Country:US
Practice Address - Phone:662-377-3270
Practice Address - Fax:662-377-4352
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF02200321363LF0000X
MS903881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily